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What type of arthritis do you think that Ethel has? Provide a rationale for your answer linking to pathophysiology. (3 marks)
Ethel has Osteoarthritis, it is the most prevalent type of arthritis among seniors. This happens mainly in the elbows, thighs, and neck. Osteoarthritis is a worldwide chronic condition of the inflammatory joints. The risk factors and biochemical parameters including cytokines, the disease caused by proteolytic enzymes (Chen, 2017). Nevertheless, as the disease progresses, cumulative cartilage deterioration outnumbers reparative attempts. Initially, fibrillation, corrosion, and cracking begin in the superficial layer of the cartilage and advance to deep layers over time.
Nurses need to understand the indications for and actions of medications they administer and make clinical decisions to ensure safe medication administration.
a) Donepezil is a commonly used medication to treat mild to moderate dementia caused by Alzheimer’s disease. Briefly describe the mode of action (pharmacodynamics) of Donepezil. (2 marks)
Donepezil is a piperidine derivative, and an acetylcholinesterase inhibitor that acts centrally, rapidly and reversibly. Acetylcholinesterase enzyme is required for the degradation of acetylcholine from the presynapse after it has released. Donepezil inhibits the hydrolysis of acetylcholine, which is needed for cognitive function, it increases the availability of acetylcholine at synapses, enhancing transmission. (Rogers & Friedhoff, 1998).
b) Discuss the nursing considerations for patients taking Donepezil and the education you would provide to the patient/family. (2 marks)
The nursing considerations for patients taking Donepezil are to assess cognitive function and monitor heart rate periodically during therapy. The family has to make sure the daily routine for medication is followed. Medicines should not be given more than recommended; higher doses can lead to side effects (Kumar & Sharma, 2020).
b) Name one (1) side effect of Donepezil and state how you would assess Ethel for this? (1 mark)
In aged patients like Ethel with arthritis, the Donepezil can cause side effects like muscle cramps.
c) Ethel takes non-steroidal anti-inflammatory drugs (NSAIDs). What is the risk for her with also taking Telmisartan? What advice can you give to reduce this risk and what monitoring should occur? (3 marks)
Ethel uses telmisartan along with non-steroidal anti-inflammatory drugs (NSAIDs) which might increase the risk of kidney disorders. The risk of being dehydrated, taking water pills (diuretics), or developing kidney problems is higher in aged patients such as Ethel. Since older adults can be more sluggish in handling the medications. A lower dose or a different regimen is given in the senior patients. The caregiver has to monitor the swelling of the limbs and blood pressure (Drug Information Group, 2018).
Review knowledge on types of dementia as it is important to understand the type of dementia that Ethel has.
Ethel has been diagnosed with Alzheimer’s dementia.
a) Outline briefly the basic pathophysiology of Alzheimer’s’ dementia. (2 marks)
AD is commonly known as diseases associated with intensifying neuronal failure, and synapses occur in distinct anatomical loci resulting in various phenotypes. The pathophysiology of Alzheimer's disease is controlled for by a variety of factors including cholinergic dysfunction, tau or amyloid toxicity, and mitochondrial dysfunction or oxidative stress. (Swerdlow, 2007).
When the family first became concerned about Mrs Simpson’s cognitive status, they visited her GP. You will do a further examination of mental status. There are many cognitive tools available that you might use to assess mental status.
b) Name and justify one (1) cognitive test that would be applicable to use for Ethel. (2 marks)
Mini-Cog, it is a very short test that can be done when taking the history, or by requesting them to repeat 3 words immediately. This also includes the clock drawing check, incorporating a word recall function which is delayed by three items.
d) Name three (3) other tests (not cognitive) a doctor might order to determine a diagnosis of Alzheimer’s dementia and explain briefly why. (3 marks)
The Alzheimer's Disease Rating Scale, BEHAVE-AD is one of the first activity assessment scales which can be used for patients. The BEHAVE-AD is immune to behavioral changes and suitable for assessing drug effects.
CERAD (Consortium to Establish an Alzheimer's Disease Registry) The scores assess behavioral symptoms over the past month.
In patients with dementia, the Pittsburgh Agitation Scale (PAS) measures agitation. Four classes of behaviors are assessed on a scale of 0–4: aberrant vocalizations, aggressiveness resistant treatment, and motor agitation (Forester & Oxman, 2003).
After reviewing NSQHS standard five, answer the following questions related to safety and comprehensive care
a) Ethel is at increased risk of injury while in hospital. Name three (3) reasons why. (3 marks)
The framework for clinical care incorporates procedures for medical care to recognize medical needs and avoid harm. It covers falls-related behavior, strain accidents, diet, mental wellbeing, cognitive impairment, and life-end treatment. Since Ethel is aged, she is most prone to getting fall injuries in the hospital settings. And recently she underwent an arthritis surgery which makes her a risk for pressure injuries. She is also suffering from dementia and this condition can make her aggressive make her susceptible to injuries.
b) Discuss two (2) interventions that you would implement to help Ethel avoid injury while she is in hospital. Justify your answer using evidence beyond the NSQHS standard. (4 marks)
Patient health measures are aimed at avoiding potential damage to patients when they are being treated. Patients are often transported for examinations; treatments can have to change beds within the unit or be moved to a new unit. Every time a shift occurs, basic safeguards such as ensuring that the call light of the patient is within reach and that the patient (Li-Yun et al., 2014).
Research indicates that falls in elderly people are caused mainly by environmental factors such as tripping, losing balance, wet floors, or insufficient lighting. In older patients, therefore, the correct lighting and furniture arrangement in the hospital is extremely important. The restroom is where the majority of falls occur and usually during everyday activities such as walking around in the house (Currie, 2008).
Ethel is having a total knee arthroplasty. Her granddaughter asks what this means. Provide a suitable explanation for her of this surgical procedure. (2 marks)
Knee arthroplasty is a surgical operation to resurface an arthritis-injured knee. Plastic and metal parts, together with the kneecap are used to cap bone ends which form joint of the knee. The aim is always to resurface the damaged parts of the knee joint and to alleviate knee pain (Varacallo et al., 2020).
Ethel has Diabetes Mellitus Type 2 (DMT2). She clearly is not overweight.
However, having DM2 poses additional risks to patients undergoing surgery. Explain two (2) of these risks and justify incorporating pathophysiology. (4 marks)
Surgery presents unique problems for patients like Ethel with diabetes because of the response to stress, food intake disturbance, mood changes, and circulatory changes all contribute to unpredictable levels of glucose and electrolyte. Postoperatively myocardial infarction is a major source of concern for diabetic patients. Postoperative, acute myocardial infarction is at elevated risk for diabetes patients. Myocardial infarction can be silent with no visible symptoms and has a higher mortality rate for diabetes sufferers.
Diabetic patients having kidney problems like diabetic nephropathy can have a bad complication and mortality result, which also raises the risk of underlying conditions such as hypertension and peripheral artery disease. (Tidy, 2016).
In the video Ethel is cooperative but forgetful.
a) Name a suitable pain assessment tool you could use to assess her pain. (0.5 marks)
The Pain Assessment in Advanced Dementia Scale (PAINAD) is a reliable assessment tool for dementia patients (You tube, 2018).
b) Justify your choice of this tool, considering Ethel’s responses to the questions in the video. (1.5 marks)
The PAINAD scale is done on a 0-to-10 visual analog scale which check leg activity, the face, controllability scale, cry, and the discomfort level for Dementia (You tube, 2018)
c) Explain briefly two (2) other indicators you might observe to assess Ethel’s pain level and justify why they are appropriate for Ethel. (2 marks)
Pain severity and pain relief are the two key areas measured in acute pain studies. Verbal Rating Scales (VRS), and Numerical Rating Scales (NRS), are the pain assessment tools that are used frequently for measuring acute pain in research and clinical settings. All of these scales are easy and can be easily grasped by older patients (Williamson, 2004).
Ethel has indicated that she currently has a poor appetite and has lost 3kgs in the last month.
a) People with Alzheimer’s dementia often suffer loss of appetite and weight loss. Explain three (3) reasons why this might be happening to Ethel. (3 marks)
Firstly, Alzheimer's patients may lose weight because they are more likely to burn more calories at regular speed, wander, and are more likely to be in motion. Secondly, the Alzheimer's patient may not eat because they're scared of something, hear voices, or maybe disturbed when dining and leave the table before the meal is finished. Thirdly, it is often seen that people may lose the ability to recognize food or forget how to use utensils to carry food into their mouths, even though they may be hungry.
Consider how Ethel’s’ dementia impacts the hospitalisation and nursing approach.
Discuss three (3) considerations you need when providing her care? (3 marks)
The nursing interventions for a dementia patient are: Patients are also sensitive to nature and the environment. Enable patients to have familiar objects around them; use certain things, such as a clock, a calendar, and regular schedules, to help maintain an orientation to reality. Don't let false theories ruminate. When that begins, think about actual people and real things for patients. The nurse should use simple explications and face-to-face contact. Speaking quietly and face to face is most effective when interacting with an elderly person who has a hearing loss (George et al., 2013).
Ethel has many nursing problems. Please write three (3) clear nursing problem statements using the “problem related to cause” format based on your review of the case and your reading of supporting evidence. (3 marks)
Patient conduct affects people including relatives and hospital roommates and staff. Therefore, due to the aggressive of patients with dementia, families, and hospital roommates, fear, anxiety, and frustration can often require nursing care. Numerous changes in the environment, anxiety when patients do not see familiar faces at the hospital, uncomfortable procedures and physical disabilities cause disturbing behaviors like fall and wander. The codes suggest that patients with dementia feel secure and calm down when they spend time with family. Dementia patients had trouble adhering to medical care and show resistance in taking medications.
State a goal for each of your nursing problems in SMART format. Please provide these SMART goals in a sentence for each goal- do not provide a table. [Three (3) goals needed] (3 marks)
a) Anxiety due to hospital environment
S- Fear of new environment
M- Distressing actions
A- Making them spend time with family
R- By giving the sense of security
T- Within two weeks
b) Resistance in taking medication
S- Not willing to take medicine
M- make patient take medicine
A- talking with patient
R- It is realistic and can be attained with good rapport
T- Within a week
c) Aggressive behaviour of patients
S- Behavioural issues
M- Patient actions
A- Evidence-based practice
R- It is realistic as the patient are anxious
T- Within a week
State two (2) nursing interventions for each of your stated problems in question 10. (6 marks)
Through avoiding unnecessary drugs and informing patients, families, caregivers and health care providers, many behavioral problems may be avoided. Hospitalization and institutionalization may be avoided by early detection and treatment of behavioral disorders (Desai et al., 2001).
One way to support people in their day-to-day lives is to change the external environment to make it easier to connect with them during the care. A systematic review looks at the breadth of studies available to people with dementia using physical environmental methods to boost everyday performance by carrying out activities outdoor (Woodbridge, 2018).
Adherence to medication remains a problem for health care providers and scientists, as their attempts to strengthen and justify patient adherence appear ineffective; inadequate adherence is associated with increased costs of health care, reduced quality of life, and adverse health outcomes. Motivating patients to seek medical attention is part of medical history (Costa et al., 2015).
For each of your three (3) nursing problems in question 10, state two (2) pieces of assessment you would use to assist you to determine effectiveness and evaluate your nursing interventions. (3 marks)
The assessment for the aggressive behavioural issues can be observed as the patients are showing improved behaviour and are cooperative and calm. This can be achieved by building the good rapport with the patient and gaining the confidence of the patient. The patient responds to the change in environment that can be managed and a familiar atmosphere can be provided to the patient and that can be assessed with the calmness and mood of the patient. Also, the patient can be asked to spend time with family members. Some activities can also be arranged to lighten the mood of the patient and the patient can interact with the other members. Thirdly the patient’s reaction can be assessed when medication as are administered. The resistance to medication administeration can be overcome with the time once the patient become familiar with the nursing staff.
Medication administration can be a specific challenge when working with people with dementia. Discuss four (4) considerations when administering medication to a person with dementia. (4 marks)
Medication monitoring is particularly important in dementia units as these patients comprise an extremely vulnerable group. Because of their dementia, patients cannot frequently give informed consent to drugs and can be non-compliant or even verbally or physically abusive on occasion. Secondly, they may feel depressed when they see too many bottles of pills. In that case, you should keep their prescription bottles from out sight and just pull out the drugs they have to take at that moment. Thirdly, many medications cause uncomfortable side effects such as nausea, stomach aches, anxiety, or dizziness and your older person might not be able to tell you there is a problem. Speak to the doctor on how to change the condition if you think this
could be the problem. Next, there is also nothing that you can do or do to convince the older person to take their medicine. If this happens, try not to bring it on. Leave them alone and you can both calm down for a little while. Giving it a try in 15 minutes.
What are two (2) specific considerations for people with arthritis in regard to management and prevention of pressure injuries? (2 marks)
Pressure injuries cause discomfort and anxiety for patients in the short and long term, and are also considered measures of insufficient quality of treatment, contributing to lawsuits. Prevention involves recognizing individuals at risk and implementing appropriate protective steps, such as enforcing a repositioning plan for patients; maintaining the head of the bed at the lowest safe level to avoid shear also by using surfaces that minimize pressure, and evaluating nutrition and supplements (Bluestein, 2008).
Review NSQHS Standards: Partnering with Consumers Standard.
After reading this Standard consider how you would partner with Ethel and her family as you deliver care.
a) Explain four (4) key actions nurses should take to ensure they meet this standard in their practice. (4 marks)
The Partnering with Consumers Standard was developed as there is good evidence delivering care that incorporates consumers’ needs and preferences. As healthcare providers, healthcare administrators, and patients work in collaboration to improve healthcare quality and safety, adverse outcomes are minimized, healthcare worker
satisfaction is increased, and patient care experience is improved. For better health results the nurse should take the holistic approach to treatment. A high-quality service in health care should be given for the best outcomes that match the norm. Staff will ensure the greater quality of care in the hospital by supplying the patients with a strong infrastructure. Finally, protection is the most important thing for good health care (NSQHS Standards, 2019).
b) Ethel has dementia and a reduced capacity for consent. How do nurses ensure that dementia patients receive safe and high-quality care through involvement in decisions and planning for future care? (2 marks)
The role of the nurse in treating dementia is through the delivery of high-quality treatment. It also addresses recovery strategies such as medication and ensuring that the nutritional needs of the patient are met, as well as the importance of treating behavioral issues sensitively that can obscure discomfort or emotional issues. Finally, it explains how the care environment can make a significant difference in the lives of people with dementia where things like basic signs and assistive devices can contribute to independence and quality of life. It could be made easier by nurses using a warm, compassionate approach and maintaining complete security of the patient's body. It is also important to appoint staff members periodically, so that they are familiar with patients and understand their specific care preferences (NSQHS Standards, 2019).
Bluestein, D. & Javaheri. A. (2008). Pressure Ulcers: Prevention, evaluation, and management. American Family Physician. 15, 78(10), 1186-1194.
Chen, D., Shen, J., Zhao, W., Wang, T., Han, L., Hamilton, J. L., & Im, H. J. (2017). Osteoarthritis: toward a comprehensive understanding of pathological mechanism. Bone Research, 5, 16044. https://doi.org/10.1038/boneres.2016.44
Costa, E., Giardini, A., Savin, M., Menditto, E., Lehane, E., Laosa, O., Pecorelli, S., Monaco, A., & Marengoni, A. (2015). Interventional tools to improve medication adherence: review of literature. Patient Preference and Adherence, 9, 1303–1314. https://doi.org/10.2147/PPA.S87551
Currie L. (2008). Fall and injury prevention. In: Hughes RG, editor. Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); Available from: https://www.ncbi.nlm.nih.gov/books/NBK2653/
Desai, A. K., & Grossberg, G. T. (2001). Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 3(3), 93-109. doi: 10.4088/pcc.v03n0301. PMID: 15014607; PMCID: PMC181170.
Drug Information Group. (2018). Telmisartan, oral tablet. Retrieved from https://www.medicalnewstoday.com/articles/telmisartan-oral-tablet#:~:text=Taking%20nonsteroidal%20anti%2Dinflammatory%20drugs,)%2C%20or%20have%20kidney%20problems.
Forester, B. P., & Oxman, T. E. (2003). Measures to assess the noncognitive symptoms of dementia in the primary care setting. Primary Care Companion to the Journal of Clinical Psychiatry, 5(4), 158–163. https://doi.org/10.4088/pcc.v05n0403
George, J., Long, S., & Vincent, C. (2013). How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. Journal of the Royal Society of Medicine, 106(9), 355–361. https://doi.org/10.1177/0141076813476497
Kumar, A., & Sharma, S. (2020). Donepezil. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513257/ Li-Yun, T., Shiow-Luan, T., Ruey-Kuen, H., Shu, Y., Jung-Mei, T., Hui-Hsien, C., & Shu-Jung, L. (2014). Fall injuries and related factors of elderly patients at a medical center in Taiwan. International Journal of Gerontology. 8(4), 203-208.
NSQHS Standards. (2019). The NSQHS standards. Retrieved from https://www.safetyandquality.gov.au/standards/nsqhs-standards
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Swerdlow R. H. (2007). Pathogenesis of Alzheimer's disease. Clinical Interventions in Aging, 2(3), 347–359.
Tidy, M (2016). Precautions for patients with diabetes undergoing surgery. Retrieved from https://patient.info/doctor/precautions-for-patients-with-diabetes-undergoing-surgery#:~:text=Patients%20with%20diabetes%20have%20a%20higher%20perioperative%20risk.,have%20complications%20from%20their%20diabetes.
Varacallo, M., & Luo, T. D., & Johanson, N. A. (2020). Total knee arthroplasty (TKA) techniques. In: StatPearls Publishing. Treasure Island (FL). Available from: https://www.ncbi.nlm.nih.gov/books/NBK499896/
Williamson, A. & Hoggart, B. (2004). Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing, 14, 798–804.
Woodbridge, R., Sullivan, M. P., Harding, E., Crutch, S., Gilhooly, K. J., Gilhooly, M., McIntyre, A., & Wilson, L. (2018). Use of the physical environment to support everyday
activities for people with dementia: A systematic review. Dementia (London, England), 17(5), 533–572. https://doi.org/10.1177/1471301216648670 You tube. (2018). Handover Video. https://www.youtube.com/watch?v=osA-1v1a440&feature=youtu.be
You tube. (2018). Mrs Simpson -Pre-admission clinic. Retrieved from https://www.youtube.com/watch?v=Nd--ZCAFbaU&feature=youtu.be
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